hospital-management/templates/patients/emergency_contacts/emergency_contact_form.html

{% extends "base.html" %}
{% load static %}

{% block title %}
    {% if object %}Edit Emergency Contact{% else %}Add Emergency Contact{% endif %} - {{ patient.get_full_name }} - {{ block.super }}
{% endblock %}

{% block content %}
<div class="container-fluid">
    <!-- Page Header -->
    <div class="d-flex justify-content-between align-items-center mb-4">
        <div>
            <h1 class="h3 mb-1">
                <i class="fas fa-user-friends me-2"></i>
                {% if object %}Edit Emergency Contact{% else %}Add Emergency Contact{% endif %}
            </h1>
            <nav aria-label="breadcrumb">
                <ol class="breadcrumb mb-0">
                    <li class="breadcrumb-item"><a href="{% url 'core:dashboard' %}">Dashboard</a></li>
                    <li class="breadcrumb-item"><a href="{% url 'patients:patient_list' %}">Patients</a></li>
                    <li class="breadcrumb-item"><a href="">{{ patient.get_full_name }}</a></li>
                    <li class="breadcrumb-item active">
                        {% if object %}Edit Contact{% else %}Add Contact{% endif %}
                    </li>
                </ol>
            </nav>
        </div>
        <div class="btn-group">
            <a href="" class="btn btn-outline-secondary">
                <i class="fas fa-arrow-left me-2"></i>Back to Patient
            </a>
        </div>
    </div>

    <div class="row justify-content-center">
        <div class="col-lg-8">
            <!-- Patient Info Card -->
            <div class="card mb-4">
                <div class="card-header bg-primary text-white">
                    <h5 class="mb-0">
                        <i class="fas fa-user me-2"></i>Patient Information
                    </h5>
                </div>
                <div class="card-body">
                    <div class="row align-items-center">
                        <div class="col-auto">
                            {% if patient.photo %}
                                <img src="{{ patient.photo.url }}" alt="Patient Photo" class="rounded-circle" style="width: 60px; height: 60px; object-fit: cover;">
                            {% else %}
                                <div class="bg-light rounded-circle d-flex align-items-center justify-content-center" style="width: 60px; height: 60px;">
                                    <i class="fas fa-user fa-2x text-muted"></i>
                                </div>
                            {% endif %}
                        </div>
                        <div class="col">
                            <h6 class="mb-1">{{ patient.get_full_name }}</h6>
                            <div class="text-muted">
                                <small>MRN: {{ patient.mrn }} | DOB: {{ patient.date_of_birth|date:"M d, Y" }}</small>
                            </div>
                        </div>
                    </div>
                </div>
            </div>

            <!-- Emergency Contact Form -->
            <div class="card">
                <div class="card-header">
                    <h5 class="mb-0">
                        <i class="fas fa-address-book me-2"></i>Contact Information
                    </h5>
                </div>
                <div class="card-body">
                    <form method="post" id="emergencyContactForm" novalidate>
                        {% csrf_token %}
                        
                        <!-- Basic Information -->
                        <div class="row">
                            <div class="col-md-6 mb-3">
                                <label for="{{ form.first_name.id_for_label }}" class="form-label">
                                    First Name <span class="text-danger">*</span>
                                </label>
                                {{ form.first_name }}
                                {% if form.first_name.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.first_name.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                            <div class="col-md-6 mb-3">
                                <label for="{{ form.last_name.id_for_label }}" class="form-label">
                                    Last Name <span class="text-danger">*</span>
                                </label>
                                {{ form.last_name }}
                                {% if form.last_name.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.last_name.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                        </div>

                        <div class="row">
                            <div class="col-md-6 mb-3">
                                <label for="{{ form.relationship.id_for_label }}" class="form-label">
                                    Relationship <span class="text-danger">*</span>
                                </label>
                                {{ form.relationship }}
                                {% if form.relationship.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.relationship.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                            <div class="col-md-6 mb-3">
                                <label for="{{ form.priority.id_for_label }}" class="form-label">
                                    Priority <span class="text-danger">*</span>
                                </label>
                                {{ form.priority }}
                                {% if form.priority.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.priority.errors.0 }}
                                    </div>
                                {% endif %}
                                <div class="form-text">1 = Highest priority, 2 = Second priority, etc.</div>
                            </div>
                        </div>

                        <!-- Contact Details -->
                        <h6 class="mt-4 mb-3">
                            <i class="fas fa-phone me-2"></i>Contact Details
                        </h6>
                        
                        <div class="row">
                            <div class="col-md-6 mb-3">
                                <label for="{{ form.phone_number.id_for_label }}" class="form-label">
                                    Primary Phone <span class="text-danger">*</span>
                                </label>
                                {{ form.phone_number }}
                                {% if form.phone_number.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.phone_number.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                            <div class="col-md-6 mb-3">
                                <label for="{{ form.mobile_number.id_for_label }}" class="form-label">Mobile Phone</label>
                                {{ form.mobile_number }}
                                {% if form.mobile_number.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.mobile_number.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                        </div>

                        <div class="mb-3">
                            <label for="{{ form.email.id_for_label }}" class="form-label">Email Address</label>
                            {{ form.email }}
                            {% if form.email.errors %}
                                <div class="invalid-feedback d-block">
                                    {{ form.email.errors.0 }}
                                </div>
                            {% endif %}
                        </div>

                        <!-- Address Information -->
                        <h6 class="mt-4 mb-3">
                            <i class="fas fa-map-marker-alt me-2"></i>Address Information
                        </h6>
                        
                        <div class="row">
                            <div class="col-md-6 mb-3">
                                <label for="{{ form.address_line_1.id_for_label }}" class="form-label">Address Line 1</label>
                                {{ form.address_line_1 }}
                                {% if form.address_line_1.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.address_line_1.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                            <div class="col-md-6 mb-3">
                                <label for="{{ form.address_line_2.id_for_label }}" class="form-label">Address Line 2</label>
                                {{ form.address_line_2 }}
                                {% if form.address_line_2.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.address_line_2.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                        </div>

                        <div class="row">
                            <div class="col-md-4 mb-3">
                                <label for="{{ form.city.id_for_label }}" class="form-label">City</label>
                                {{ form.city }}
                                {% if form.city.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.city.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                            <div class="col-md-4 mb-3">
                                <label for="{{ form.state.id_for_label }}" class="form-label">State</label>
                                {{ form.state }}
                                {% if form.state.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.state.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                            <div class="col-md-4 mb-3">
                                <label for="{{ form.zip_code.id_for_label }}" class="form-label">ZIP Code</label>
                                {{ form.zip_code }}
                                {% if form.zip_code.errors %}
                                    <div class="invalid-feedback d-block">
                                        {{ form.zip_code.errors.0 }}
                                    </div>
                                {% endif %}
                            </div>
                        </div>

                        <!-- Authorization Settings -->
                        <h6 class="mt-4 mb-3">
                            <i class="fas fa-shield-alt me-2"></i>Authorization Settings
                        </h6>
                        
                        <div class="row">
                            <div class="col-md-4 mb-3">
                                <div class="form-check">
                                    {{ form.is_authorized_for_medical_decisions }}
                                    <label class="form-check-label" for="{{ form.is_authorized_for_medical_decisions.id_for_label }}">
                                        <strong>Medical Decisions</strong><br>
                                        <small class="text-muted">Can make medical decisions for patient</small>
                                    </label>
                                </div>
                            </div>
                            <div class="col-md-4 mb-3">
                                <div class="form-check">
                                    {{ form.is_authorized_for_financial_decisions }}
                                    <label class="form-check-label" for="{{ form.is_authorized_for_financial_decisions.id_for_label }}">
                                        <strong>Financial Decisions</strong><br>
                                        <small class="text-muted">Can make financial decisions for patient</small>
                                    </label>
                                </div>
                            </div>
                            <div class="col-md-4 mb-3">
                                <div class="form-check">
                                    {{ form.is_authorized_for_information }}
                                    <label class="form-check-label" for="{{ form.is_authorized_for_information.id_for_label }}">
                                        <strong>Medical Information</strong><br>
                                        <small class="text-muted">Can receive medical information</small>
                                    </label>
                                </div>
                            </div>
                        </div>

                        <!-- Additional Notes -->
                        <div class="mb-3">
                            <label for="{{ form.notes.id_for_label }}" class="form-label">
                                <i class="fas fa-sticky-note me-2"></i>Additional Notes
                            </label>
                            {{ form.notes }}
                            {% if form.notes.errors %}
                                <div class="invalid-feedback d-block">
                                    {{ form.notes.errors.0 }}
                                </div>
                            {% endif %}
                            <div class="form-text">Any additional information about this emergency contact</div>
                        </div>

                        <!-- Status -->
                        <div class="mb-4">
                            <div class="form-check">
                                {{ form.is_active }}
                                <label class="form-check-label" for="{{ form.is_active.id_for_label }}">
                                    <strong>Active Contact</strong>
                                    <br><small class="text-muted">Uncheck to deactivate this emergency contact</small>
                                </label>
                            </div>
                        </div>

                        <!-- Form Actions -->
                        <hr>
                        <div class="d-flex justify-content-between align-items-center">
                            <div>
                                <a href="" class="btn btn-secondary">
                                    <i class="fas fa-times me-2"></i>Cancel
                                </a>
                            </div>
                            
                            <div class="btn-group">
                                <button type="button" class="btn btn-outline-secondary" onclick="resetForm()">
                                    <i class="fas fa-undo me-2"></i>Reset
                                </button>
                                <button type="submit" class="btn btn-primary">
                                    <i class="fas fa-save me-2"></i>
                                    {% if object %}Update Contact{% else %}Add Contact{% endif %}
                                </button>
                            </div>
                        </div>
                    </form>
                </div>
            </div>
        </div>
    </div>
</div>

<script>
document.addEventListener('DOMContentLoaded', function() {
    // Form validation
    const form = document.getElementById('emergencyContactForm');
    form.addEventListener('submit', function(event) {
        if (!form.checkValidity()) {
            event.preventDefault();
            event.stopPropagation();
        }
        form.classList.add('was-validated');
    });
    
    // Auto-format phone numbers
    const phoneInputs = document.querySelectorAll('input[type="tel"]');
    phoneInputs.forEach(function(input) {
        input.addEventListener('input', function(e) {
            let value = e.target.value.replace(/\D/g, '');
            if (value.length >= 6) {
                value = value.replace(/(\d{3})(\d{3})(\d{4})/, '($1) $2-$3');
            } else if (value.length >= 3) {
                value = value.replace(/(\d{3})(\d{3})/, '($1) $2');
            }
            e.target.value = value;
        });
    });
    
    // Priority validation
    const priorityInput = document.querySelector('input[name="priority"]');
    if (priorityInput) {
        priorityInput.addEventListener('input', function(e) {
            const value = parseInt(e.target.value);
            if (value < 1) {
                e.target.value = 1;
            } else if (value > 10) {
                e.target.value = 10;
            }
        });
    }
});

// Reset form function
function resetForm() {
    if (confirm('Are you sure you want to reset the form? All unsaved changes will be lost.')) {
        document.getElementById('emergencyContactForm').reset();
        document.getElementById('emergencyContactForm').classList.remove('was-validated');
    }
}

// Auto-save functionality (optional)
let autoSaveTimer;
function autoSave() {
    clearTimeout(autoSaveTimer);
    autoSaveTimer = setTimeout(function() {
        // Implement auto-save logic here if needed
        console.log('Auto-saving emergency contact...');
    }, 30000); // Auto-save every 30 seconds
}

// Trigger auto-save on form changes
document.getElementById('emergencyContactForm').addEventListener('input', autoSave);
</script>

<style>
.form-control, .form-select {
    border-radius: 0.375rem;
    border: 1px solid #ced4da;
    transition: border-color 0.15s ease-in-out, box-shadow 0.15s ease-in-out;
}

.form-control:focus, .form-select:focus {
    border-color: #86b7fe;
    outline: 0;
    box-shadow: 0 0 0 0.25rem rgba(13, 110, 253, 0.25);
}

.card {
    box-shadow: 0 0.125rem 0.25rem rgba(0, 0, 0, 0.075);
    border: 1px solid rgba(0, 0, 0, 0.125);
}

.card-header {
    background-color: rgba(13, 110, 253, 0.1);
    border-bottom: 1px solid rgba(0, 0, 0, 0.125);
}

.card-header.bg-primary {
    background-color: #0d6efd !important;
}

.btn {
    border-radius: 0.375rem;
    transition: all 0.15s ease-in-out;
}

.btn:hover {
    transform: translateY(-1px);
    box-shadow: 0 4px 8px rgba(0, 0, 0, 0.1);
}

.form-check-input:checked {
    background-color: #0d6efd;
    border-color: #0d6efd;
}

.invalid-feedback {
    font-size: 0.875rem;
}

.form-text {
    font-size: 0.875rem;
    color: #6c757d;
}

h6 {
    color: #495057;
    font-weight: 600;
}

@media (max-width: 768px) {
    .btn-group {
        display: flex;
        flex-direction: column;
        gap: 0.5rem;
    }
    
    .d-flex.justify-content-between {
        flex-direction: column;
        gap: 1rem;
    }
}
</style>
{% endblock %}